Pharmacist and Certified Respiratory Educator (CRE) Dorothy Pardalis has made a personal commitment to improving asthma management in her Windsor, Ont. community.
By Mike Boivin, BSc.Phm.
Noting that some patients with asthma are uncontrolled1[1A, P673], the pharmacist at McGaffey Medical Pharmacy has seen first-hand the positive effect community pharmacists can have on improving control. “For most patients with asthma, it just takes pharmacists to initiate dialogue with patients about their asthma, intervene and recommend the appropriate treatments,” she says. “I have seen how proper asthma management is transformational for patients in my practice. Asthma is one of those conditions where patients just accept poor control as the norm.”
Dorothy notes a lack of education among many patients with asthma, as many accept that frequent use of short-acting bronchodilators to do basic daily activities is normal. “Many simply adjust their lifestyles because of their symptoms and determine that being short of breath is part of having asthma. I have seen that with the right education, choosing the appropriate controller therapy and long-term adherence, the majority of my patients can achieve control.”
Dorothy has become a champion of respiratory health in her community. “When encountering poorly controlled asthma, we have a responsibility to act and address problems with therapy. Even some healthcare professionals have accepted that poor asthma control is normal. I have found when a pharmacist intervenes, educates and makes therapy recommendations, most patients and prescribers are very receptive.”
In her community pharmacy practice, Dorothy is constantly monitoring her patients with asthma. “We have to remember that asthma is a chronic disease, requiring education not only at the time of diagnosis but over the course of the illness,” she says. “It is easy for pharmacists to frequently assess a patient’s asthma control, adherence and inhaler technique with a relatively small time commitment.”
Dorothy finds that by using the Canadian Thoracic Society’s criteria for asthma control, she can assess a patient’s control in under a minute.2 [2B, P18] “It just takes a few questions to assess symptoms, impairments in physical activity, and short-acting bronchodilator use to ensure optimal management.”
There are many reasons for poor asthma control, she explains, but one of the key issues is poor adherence to controller medication. Adherence to medications is a major issue in patients with asthma. Studies with children and adults have shown that around 50 per cent of those on long-term therapy fail to take their medication as directed at least part of the time.3 [3A, P18]
How can pharmacists identify poor adherence in their practices?
- Medication profile.
- Pharmacists can quickly assess adherence by checking the last fill dates in the dispensing system for both bronchodilators and controller medications. If the patient is controlled, a 200 dose salbutamol inhaler should last around 230 days†.2,4 [2B, P18] [4A, P11]
- Asthma control assessment
- Patients who are poorly adherent to therapy will commonly see deterioration in their asthma control. Even if they are adherent, poorly controlled patients might require an adjustment or addition to their therapy.2 [2C, P17]
- Medication reviews
- A medication review is an excellent opportunity to assess many aspects of asthma management. Pharmacists can assess asthma control, adherence to therapy, inhaler technique, triggers and environmental control, and address any educational gaps.
- Quick asthma checks
- Dorothy counsels her patients with asthma regularly when they are picking up refills. “Several times a year, I ask my patients with asthma open-ended questions to assess their thoughts on their control, medications and adherence. I also review inhaler technique, which is often suboptimal.”
How can pharmacists intervene in non-adherent patients?
- Address the myths and patient concerns. “Many of my patients are concerned about inhaled corticosteroid adverse effects,” says Dorothy. “I provide education regarding the safety profile of these products. I also recommend the products with the best safety profiles and the lowest incidence of thrush and systemic adverse effects.” Encouraging the use of a spacer device with metered dose inhalers and rinsing after use are also effective strategies to minimize local side effects (e.g. oropharyngeal candidiasis, dysphonia, cough from upper airway irritation) .2 [2D, P18]
- Simplify the regimen. “I am constantly looking for ways to simplify my patient’s regimen,” she notes. “I step up therapy during times of poor control and step down once controlled has been reached. I choose therapies that are easiest to use and fit into a patient’s lifestyle. ” It is also critical to ensure the patient is using the appropriate device in terms of patient preference and the ability to achieve optimal delivery of the medication.
- Focus on education. Since asthma is a chronic disease, Dorothy regularly provides education regarding the condition, its treatment and ways to improve quality of life. “I often challenge patients to try using their controller therapy regularly for two months and they are amazed at the difference in their breathing and activity level.”
“Asthma is a condition that does not have to reduce a patient’s quality of life, and pharmacists who regularly assess and intervene to simplify and optimize medication regimens can dramatically improve asthma outcomes,” says Dorothy. “Helping an asthma patient achieve control is incredibly rewarding and strengthens the trust and alliance between the pharmacist and the patient.”
- McIvor RA, Boulet L-P, FitzGerald JM, Zimmerman S, Chapman KR. Asthma control in Canada. Can. Fam. Physician 2007;53(4):672 -677.
- Lougheed MD, Lemière C, Dell SD, et al. Canadian Thoracic Society Asthma Management Continuum – 2010 Consensus Summary for children six years of age and over, and adults. Can. Respir. J. J. Can. Thorac. Soc. 2010;17(1):15-24.
- Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention.; 2014. Available at: http://www.ginasthma.org/. Accessed March 14, 2014.
- GlaxoSmithKline. Ventolin(R) HFA Product Monograph. Mississauga, Ontario: Glaxo Smith Kline; 2014.
† Extrapolation of CTS Guidelines and Ventolin® HFA product monograph. Standard dose of salbutamol is 1-2 puffs and the MDI inhaler contains 200 doses. The measure of control is <4 doses per week. Patients using 2 puffs up to 3 times weekly = 6 puffs per week 200/6 = 33.3 weeks = 233 days or approximately 230 days.